Pharm CH 27- Antipsychotics & Anxiolytics

piperidines phenothiazines

ex. Thioridazine HCl (Mellaril) Side effects: few EPS, strong sedation

aliphatic phenothiazines

ex. chlorpromazine (Thorazine) Side effects: strong sedation, severe orthostatic hypotension, moderate EPS

piperazine phenothiazines

ex. fluphenazine (Prolixin) and perphenazine (Trilafon) Side effects: low sedation, strong antiemetic effect, severe EPS

The nurse realizes more medication teaching is necessary when the 30-year-old patient taking lorazepam (Ativan) states "I must stop drinking coffee and colas." "I can stop this drug after 3 weeks if I feel better." "I must stop drinking alcoholic beverages." "I should not become pregnant while taking this drug."

"I can stop this drug after 3 weeks if I feel better." Rationale: Lorazepam should not be discontinued abruptly, but gradually, over a period of several days. Caffeine and alcohol should be avoided when taking lorazepam, a benzodiazepine. This drug should not be taken during pregnancy because of possible teratogenic effects.

Which statement by a patient indicates that more teaching on phenothiazine therapy for the treatment of psychosis is needed? "It might take 6 weeks or more for the drug to take effect." "I will get up slowly from a seated position." "When I start to feel better, I will cut the dose of my medication in half." "I will avoid exposure to direct sunlight."

"When I start to feel better, I will cut the dose of my medication in half." Rationale: The drug should be taken exactly as ordered. Antipsychotics do not cure the mental illness but do alleviate symptoms. Compliance with drug regimen is extremely important.

phenothiazines

(& thioxanthenes) block norepinephrine, causing sedative and hypotensive effects early in treatment

Akathisia

(adverse rxn for EPS) Constant motion (pacing)

acute dystonia

(adverse rxn for EPS) Muscle spasms of face, tongue, neck, and back Facial grimacing Involuntary upward eye movements Laryngeal spasms

Haloperidol (Haldol)

(nonphenothiazine) Blocks dopamine receptors; used to Treat acute and chronic psychoses, dementia & Treat schizophrenia & Treats Tourette's syndrome

Fluphenazine (Prolixin) & its side effects

(phenothiazines) -Blocks dopamine receptors in brain -Manages symptoms of schizophrenia -Increase depression when taken with alcohol or other CNS depressants; kava kava may increase EPS Side effects: Sedation, dizziness, headache, seizures Dry mouth, nasal congestion, blurred vision, photosensitivity, urinary retention GI distress, peripheral edema, tachycardia, EPS

Buspirone hydrochloride (BuSpar)

-Binds to serotonin and dopamine receptors -May not be effective until 1 to 2 weeks after continuous use -Has fewer side effects of sedation and physical and psychological dependency associated with many benzodiazepines -Most common side effects: drowsiness, dizziness, headache, nausea, nervousness, and excitement Interaction with grapefruit juice can lead to toxicity.

treatment for NMS

-Immediate withdrawal of antipsychotics -hydration, hypothermic blankets, antipyretics -benzodiazepines, muscle relaxants

Lorazepam (Ativan) interactions

-Increases CNS depression with alcohol, other CNS depressants, cimetidine -Increases lorazepam plasma levels -Increases phenytoin levels -Decreases levodopa effects -Smoking decreases antianxiety effects -Kava kava may potentiate sedation

more nursing interventions for antipsychotics

-Monitor for EPS, NMS, WBCs. -May turn urine pink to red brown. -Warn patient that drug may take 3 to 6 weeks to achieve effectiveness. -Encourage smoking cessation. -Warn patient not to combine drug with alcohol, narcotics, or other CNS depressants. -Warn against sudden discontinuation of antipsychotics to avoid sudden recurrence of psychotic symptoms.

more nursing interventions for anxiolytics

-Monitor patient for "cheeking" of medication. -Warn patient not to concurrently take CNS -depressants, alcohol, or other anxiolytics. -Warn against taking antacids and caffeine at the same time, which delays absorption and decreases effects. -Kava kava increases the sedative effects of the drug. -Patient should take with meals or shortly after to decrease GI discomfort. -Warn patient against abrupt discontinuation of drug.

nursing interventions for anxiolytics

-Monitor vital signs. -Encourage patient to rise slowly to avoid dizziness. -Warn patient that therapeutic response may take 1 to 2 weeks. -Advise patient not to drive a motor vehicle or operate dangerous equipment. -Patient should not use for more than 3 to 4 months as tolerance develops and effectiveness decreases.

positive symptoms of schizophrenia

Agitation Delusions Paranoia Hallucinations Incoherent speech

Schizophrenia

Chronic psychotic disorder Usually occurs in adolescence or early adulthood Major category of psychosis in which many of these symptoms are manifested

examples of Atypical Antipsychotics

Clozapine (Clozaril) Olanzapine (Zyprexa) Quetiapine (Seroquel) Asenapine (Saphris) Risperidone (Risperdal) Ziprasidone (Geodon) Iloperidone (Fanapt) Paliperidone (Invega, Invega Sustenna) Aripiprazole (Abilify)

A patient has been diagnosed with neuroleptic malignant syndrome. The nurse anticipates administration of which medication to treat this patient? Dantrolene (Dantrium) Tetrabenazine (Xenazine) Propranolol (Inderal) Lorazepam (Ativan)

Dantrolene (Dantrium) Rationale: Treatment of NMS involves immediate withdrawal of antipsychotics, adequate hydration, hypothermic blankets, and administration of antipyretics, benzodiazepines, and muscle relaxants such as dantrolene (Dantrium). Tetrabenazine (Xenazine), used to improve symptoms of Huntington's disease, seems to be effective in treating tardive dyskinesia. Propanolol (Inderal) has been found to be effective in the treatment of akathisia. Acute dystonia may be treated with lorazepam (Ativan).

withdrawal of anxiolytics

Develops slowly, in 2 to 10 days, and may last several weeks; Tremor, agitation, nervousness, sweating, insomnia, anorexia, muscle cramps

contraindications of Risperdal

Dysrhythmias, blood dyscrasias, liver damage

A young woman is being treated for psychosis with fluphenazine (Prolixin). Which sign would indicate the need to add an anticholinergic to the patient's medication regimen? A decrease in pulse and respiratory rate Facial grimacing and tongue spasms An increase in hallucinations A decrease in the patient's level of orientation

Facial grimacing and tongue spasms Rationale: Pseudoparkinsonism, which resembles symptoms of Parkinson's disease, is a major side effect of typical antipsychotic drugs such as fluphenazine (Prolixin). Anticholinergic medications may be used to control this side effect.

interactions w/ Risperdal

Increased effects of antihypertensives Decreased risperidone levels with concurrent use of carbamazepine

interactions with Haldol

Increased sedation with alcohol, CNS depressants Increased toxicity with anticholinergics Decreased effects with phenobarbital, carbamazepine, caffeine

Lorazepam (Ativan) (uses & side effects)

Inhibits GABA neurotransmission by binding to specific benzodiazepine receptors Uses- Anxiolytic, anticonvulsant, preoperative drug Side effects- Drowsiness, dizziness, confusion Blurred vision Weakness, restlessness Sleep disturbance, hallucinations GI distress

negative symptoms of schizophrenia

Poor self-care Poverty of speech Social withdrawal

primary anxiety

It is not caused by a medical condition or drug use. It is managed with short-term anxiolytics.

secondary anxiety

It is related to selected drug use, medical or psychiatric conditions. Medications are not usually given for secondary anxiety.

Psychosis

Losing contact with reality Manifested in a variety of mental or psychiatric disorders

nursing interventions for antipsychotics

Monitor vital signs. Monitor patient for "cheeking" medications. Give oral drugs with food or milk. Give IM by Z track into deep muscle using large-gauge needle. Do not massage injection site. Rotate injection sites. Do not allow drug to remain in plastic syringe. Administer drug within 15 minutes of preparation.

contraindications of Haldol

Narrow-angle glaucoma Sedation Severe liver, kidney, and cardiovascular disease Blood dyscrasias

side effects of Haldol

Sedation, headache, seizures EPS Dry mouth, blurred vision, photosensitivity Tachycardia, orthostatic hypotension, dysrhythmias Urinary retention

Pseudoparkinsonism (EPS) symptoms

Stooped posture Masklike features Rigidity Tremors at rest Shuffling gait Bradykinesia Pill-rolling motion of the hand

Benzodiazepines & examples

anxiolytic (antianxiety drug) used for sever/ prolonged anxiety ex. Chlordiazepoxide (Librium) Diazepam (Valium) Clorazepate dipotassium (Tranxene) Lorazepam (Ativan) Alprazolam (Xanax)

Aripiprazole (Abilify)

atypical antipsychotic Advantages: Effective in treating both positive and negative symptoms of schizophrenia; Less likely to cause EPS or tardive dyskinesia Action: Block serotonin and dopaminergic D4 receptors

Clozapine (Clozaril)

atypical antipsychotic Adverse effect: Agranulocytosis Nursing interventions: Monitor weekly WBC counts.

Olanzapine (Zyprexa)

atypical antipsychotic Does not cause EPS or agranulocytosis Side effects/adverse effects: Headaches, dizziness, agitation, Insomnia, somnolence

Risperidone (Risperdal)

atypical antipsychotic Used to manage symptoms of psychosis, schizophrenia Side effects/adverse reactions: Sedation, headaches, photosensitivity, EPS, seizures, Dry mouth, weight gain, Tachycardia, orthostatic hypotension, Urinary retention, sexual dysfunction

antipsychotic agents

block action of dopamine 2 categories- typical & a typical (cause EPS & Parkinson's)

Assessment findings for a patient with neuroleptic malignant syndrome (NMS) include bradycardia. hypothermia. muscle weakness. rhabdomyolysis.

rhabdomyolysis. Rationale: NMS symptoms include muscle rigidity, sudden high fever, altered mental status, blood pressure fluctuations, tachycardia, dysrhythmias, seizures, rhabdomyolysis, acute renal failure, respiratory failure, and coma.

Atypical antipsychotics

-1st one ever: Clozapine (not really used anymore) -Effective for treating schizophrenia and other psychotic disorders in patients who do not respond to or are intolerant of typical antipsychotics -Decreased side effects -Often used instead of traditional typical antipsychotics as first-line therapy

symptoms of psychosis

difficulty in processing information and coming to a conclusion, delusions, hallucinations, incoherence, catatonia, and aggressive or violent behavior

nonphenothiazines

include butyrophenones; blocks only the neurotransmitter of dopamine ex. Haldol

A patient on risperidone (Risperdal) may be at increased risk for injury due to -increased potential for aspiration due to sedation. -increased risk for falls due to orthostatic hypotension. -increased risk for infection due to neutropenia. -increased risk for suicide due to changes in thought processes.

increased risk for falls due to orthostatic hypotension. Rationale: Orthostatic hypotension is the most common adverse reaction seen in patients treated with risperidone (Risperdal).

2 groups of typical antipsychotics

phenothiazines and nonphenothiazines

tardive dyskinesia (TD)

protrusion & rolling of tongue, chewing action

Neuroleptic Malignant Syndrome (NMS) & symptoms

rare, potentially fatal condition associated w/ antipsychotic drugs Symptoms: Altered mental status, seizures Muscle rigidity, sudden high fever BP fluctuations, tachycardia, dysrhythmias Rhabdomyolysis, acute renal failure Respiratory failure, coma

A nurse caring for a patient in an outpatient setting notes that the patient is currently taking lorazepam (Ativan) for anxiety and her breath smells of alcohol. The nurse reports this to the health care provider because -taking alcohol with Ativan can be fatal. -taking alcohol with Ativan may increase sedative effects. -all patients using alcohol should be referred for assistance. -Ativan and alcohol antagonize one another.

taking alcohol with Ativan may increase sedative effects. Rationale: Alcohol and other CNS depressants should not be taken with benzodiazepines because respiratory depression could result.